Provider Demographics
NPI:1700165917
Name:DURSCHLAG, MATTHEW (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:DURSCHLAG
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11921 CARMEL CREEK RD APT 109
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2566
Mailing Address - Country:US
Mailing Address - Phone:858-248-7005
Mailing Address - Fax:
Practice Address - Street 1:239 LAUREL ST STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1473
Practice Address - Country:US
Practice Address - Phone:619-291-5266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX336581223X0400X
CA605581223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics